Soft tissue management: flap design, incision, tissue elevation and tissue retraction

The ultimate goal in surgical endodontics is not only the eradication of periapical pathosis but also preservation of periodontal conditions using suitable surgical techniques. Acceptable treatment outcomes are no longer possible without consideration of esthetic consequences for all involved dentoalveolar structures. During surgical endodontics the cortical bone is exposed by incising, elevating, and reflecting a full-thickness tissue flap. Certain basic principles must be considered before deciding on the type of incision and flap design. Thorough knowledge of regional anatomical structures in conjunction, as well as prevailing periodontal conditions affect and must be considered when making the proper decision on how and where to reflect the mucoperiosteal tissues. Various modes of incision can be selected, including horizontal, sulcular, submarginal, and vertical releasing incisions. The variety of flaps reflects the number of variables to be considered before choosing an appropriate flap design. While many flap designs have been suggested over the years, some have become obsolete and new techniques have emerged. It is critical that incisions and tissue elevations and reflections are performed in a way that facilitates healing by primary intention. This can be obtained by complete and sharp incision avoiding severing or traumatizing the tissues during elevation; it is equally important to prevent drying of tissue remnants on the root surface and drying of the flap during the procedure. The introduction of microsurgery to surgical endodontics attempts to minimize trauma and to enhance surgical results. Because of the combination of magnification and more delicate instruments, improved and careful tissue handling has become possible. Additional improvements in flap design and soft tissue manipulation are considered key elements in enhanced biological and esthetic outcomes of marginal soft tissues